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Understand the Affordable Care Act impact on consumers, insurance industry, physicians, and payment rules. Learn about benefits, insurance exchanges, tax credits, and more.
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Federal Health Care Law Update Marc D. Price, D.O. Family Medicine of Malta Mechanicville, N.Y. NYSAFP Board of Directors NYSAFP Advocacy Commission, Chairman AAFP Commission on Government Advocacy, Member
Overview • Brief explanation of The Affordable Care Act • Impact of The Affordable Care Act • Consumers • Insurance industry • Physicians • Physician Payment Rule 2011 • Overview of benefits for primary care • HITECH Act • AAFP efforts
The Affordable Care Act • 3/23/10 - The Patient Protection and Affordable Care Act • Amended 3/30/10 – Health Care And Education Reconciliation Act • Goal • To end some of the worst abuses by the insurance industry and to award Americans new rights and benefits • 4 Year roll implementation
The Affordable Care Act:Impact to the Consumer • Prevent Discrimination against pre-existing conditions, gender and health status • Prohibits denial of children (up to 19 yo)-now • Total prohibition (regardless of age) in 2014 • “Pre-existing condition insurance plan” to bridge the gap • Young adults up to age 26 yo may remain on a parent’s plan-now
The Affordable Care Act:Impact to the Consumer • Prohibits insurance companies from rescinding coverage when patients fall ill-now • Continuation of Child Health Insurance Program (CHIP) x 2 more years-now • Removes lifetime dollar limits on “essential benefits”-now • Restricts annual dollar limits • Completely phased out by 2014
The Affordable Care Act:Impact to the Consumer • Small business (<25 FTE) tax credits to offset cost of offering employee health insurance • 35% presently (25% for non-profits)-now • 50% by 2014 (35% for non-profits) • Tax credits or cost sharing • Middle class without other affordable alternatives • Early Retiree Reinsurance Program • Assistance to employers to offer insurance to employees retiring between the ages of 55-65 yo-now
The Affordable Care Act:Impact to the Consumer • Establishment of Health Insurance Exchanges • For those not offered employer sponsored insurance • Competitive insurance company “marketplace” • Tax credits/matching funds may be used • Same as offered to members of congress
The Affordable Care Act:Impact to the Consumer • Ensures Insurance companies to cover those participating in clinical trials • Requires all uninsured individuals to obtain health insurance • Partial or full funding available based on need • Exemptions available if no affordable alternative available • Contested as unconstitutional
The Affordable Care Act:Impact to the Consumer • Federal grants to states for Consumer Assistance Programs • Aimed at assisting consumers in understanding and navigating through insurance plans-now • Rights to consumers to appeal coverage decisions • Makes available an external appeal process if consumer is not satisfied with the internal appeal decision-now
The Affordable Care Act:Impact to the Consumer • Federal funds offered to states to offer a Community First Choice option • Offer of home based services to disabled individuals prior to institutionalized care-October 2011 • Community Care Transition Program • Helps to transition patients back to community services after hospitalization to prevent readmission-now
The Affordable Care Act:Impact to the Consumer • Closing the Medicare “donut hole” in part D drug coverage • 50% discount on name-brand and 7% on generic for 2011-now • Coverage gap gradually phased out by 2020 • Medicare coverage of annual wellness visits • No out-of-pocket cost to the consumer-now • Coverage of preventive services • No out-of-pocket cost to consumer (ie. copay, coinsurance or deductible)-now
The Affordable Care Act:Impact to the Consumer • Federal Medical Assistance Percentage (FMAP) • Federal funds to expand Medicaid services • Preventive care-now • Increased ability to cover more individuals and families-now • Availability of Medicaid to those at 133% of the poverty level by 2014 • 100% Federally funded x 3 yrs starting in 2014 then decreasing to 90% federal funding
The Affordable Care Act:Impact to the Insurance Industry • Increased expenditure on improvement in health care quality and services • 85% of premium dollars collected by large employer plans (80% individuals and small employer plans)-now • Penalties if measures not met • Decreasing the cost of Medicare Advantage plans to neutrality with general Medicare
The Affordable Care Act:Impact to the Insurance Industry • Standardization of billing codes/practices-planning phase • Adoption and implementation of rules and regulations for electronic health exchanges and electronic health records (EHR)-starting • Federal health plans required to collect and report data on racial, ethnic and language disparities-starting
The Affordable Care Act:Impact to the Insurance Industry • Federal grants (up to $250 million) to states that already have, or will be implementing measures that require insurance companies to justify premium increases-now • Companies with excessive profits or unjustified increases may not be able to participate in the 2014 health exchanges
The Affordable Care Act:Impact to the Insurance Industry • Mandate to the Centers for Medicare and Medicaid Services to develop, support and test innovations in health care delivery and efficiency • Development of the Independent Payment Advisory Board (IPAB) • Directed to develop means by which to extend the Medicare Trust Fund by cutting waste, improving efficiency and increasing quality of delivered care-developing
The Affordable Care Act:Impact to the Insurance Industry • Community Living Assistance Services and Supports (CLASS) Act • Creation of a voluntary long-term care insurance program offered through employers • A note about the new rules and insurance plans • These apply to all Medicare and Medicaid programs and any group or employer plans and insurance companies or plans which were started after 3/23/10 • Individual or family plans purchased independently prior to 3/23/10 are not required to adhere to many of these rules and are considered “grandfather” plans
The Affordable Care Act:Impact to the Physicians • Expansion of the primary care workforce • Tax incentives, scholarships and loan repayment to work in underserved populations-now • $250 million dedicated to training more primary care providers (physicians, NPs, PAs)-now • Goal of 16,000 more primary care physicians over the next 5 years • Includes funding for support of IT infrastructure-now • Increased funding to support construction and expansion of community health programs-now
The Affordable Care Act:Impact to the Physicians • Incentives for physicians to form Accountable Care Organizations (ACO) • Large organizations of physicians and administrators who assume risk in efforts to improve outcomes and decrease costs • Various models, no consensus on specifics yet • Hospital value-based purchasing program • Reimbursement linked to hospital performance • Publicly reported outcomes
The Affordable Care Act:Impact to the Physicians • Bundling of payments • Combined “flat rate” reimbursement for a “whole package” of services (ie. radiology, lab, physician, hospital and other provider service fees) • Increased reimbursement to rural health providers • Meant to attract and retain providers to these areas
The Affordable Care Act:Impact to the Physicians • Increased Medicaid payment • Equal to Medicare in 2013 and 2014 • Fully federally funded • Increased payment to physicians by 2015 based on quality of care and not volume
The Affordable Care Act • Estimated deficit reduction • > $100 Billion over 10 years • > $1 Trillion over 20 years • More information • HealthCareAndYou.org
The Affordable Care Act • Barriers to implementation • Constitutionality lawsuits • House of Representatives efforts • Votes to repeal • Denial of funding • Senate efforts • ICD-10 code modification/derailment
Physician Payment Rule 2011 • Waves Medicare part B deductible and the 20% coinsurance for preventive services • Increased payment levels for E&M codes • 99213 Payment 56% higher than 2006 level • 99214 Payment 48% higher than 2006 level • 10% Medicare primary care bonus • Estimated 80% of FPs will qualify
Physician Payment Rule 2011 • Sustainable Growth Rate (SGR) not repealed but extension passed for 2011, delaying 23% Medicare payment reduction • 29.5% Medicare payment reduction in 2012 if SGR not repealed or delayed again • Decreased payment to some specialties (ie. Cardiology and nuclear medicine) based on practice expense revisions • Continued elimination of consultation codes
Physician Payment Rule 2011 • Continue to support e-prescribing and Physician Reporting Quality initiative (PQRI) • Less incentive payment than 2010 • Phasing out with payment reduction afterwards • PQRI changing name to Physician Quality Reporting System (PQRS) • Can’t receive both EHR and e-prescribing incentives
Physician Payment Rule 2011 • Improved payment for intranasal and oral immunizations • Improved payment for vaccine counseling/administration • Support/payment of provisions as provided for in the Affordable Care Act • Annual Medicare well visit • Removal of barriers to preventive screening • etc
HITECH Act • Health Information Technology for Economic and Clinical Health (HITECH) Act • Goal • To improve American health care delivery patient care through an unprecedented investment in health information technology (HIT) • Achieved through support, coordination, connectivity and promotion of the meaningful use of EHR
HITECH Act • Health information technology research centers (HITRC) • To research and gather measures with proven efficacy of achieving goals • Regional extension centers (REC) • Disseminate useful information, support and assist with implementation of measures
HITECH Act • Goals of HITRC/REC • Provide outreach within the next 2 years to at lease 100,000 patient centered medical systems • Support health information exchanges • Support Strategic Health Information Technology Advanced Research Projects (SHARP) program • Measures to expand the HIT support workforce • Non-degree curriculum development and training support through grants and competency programs
HITECH Act • EHR Meaningful use incentives • Medicare – up to $44,000 per provider over 5 years • Reimbursement reduction if non-compliance by 2015 • Medicaid – up to $63,750 per provider over 6 years • No Reimbursement reduction if non-compliant • Providers may only participate with one incentive • Hospitals may participate in both incentives
AAFP Efforts • The definition of meaningful use in the EHR incentive program • Advising CMS on graduate medical education (GME) outpatient payment system • Advising appropriate government agents as to the AAFP principles of ACO • Provided feedback on the Department of Health and Human Services (HHS) National Healthcare Quality Strategy and Plan
AAFP Efforts • Cautioned CMS to not solely base their reimbursement rates on the recommendations of the AMA’s Relative Value Scale Update Committee (RUC) • Successfully advocated for exceptions to the Medicare PCP bonus eligibility criteria for rural physicians • Continuously nominating family physicians to serve on federal councils which are and will be affecting the future of medicine
Sources • www.aafp.org • www.healthcareandyou.org • www.ama-assn.org • www.healthcare.gov • www.cms.gov • www.avalerehealth.net • www.healthit.hhs.gov
Definitely NOT the end! • Questions?